CLINICAL NUTRITION MANAGEMENT OF SUPERIOR MESENTERIC ARTERY
THROMBOSIS Dana Magee ARAMARK Distance Dietetic Internship
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OVERVIEW Disease Description Evidenced Based Nutrition
Recommendations Case Presentation Nutrition Care Process Assessment
Nutrition Diagnosis Interventions Monitoring and Evaluation
Conclusion
OCCLUSIVE MESENTERIC ISCHEMIA EmbolusThrombosis 50% of AMI
cases25% of AMI cases Occurs in distal branchesOccur at origin of
SMA Quick onsetGradual onset Low collateral blood flowLarger
portion of bowel affected Smaller portion of bowel affected Can
affect multiple arteries Associated with MI, mitral stenosis, Afib,
endocarditis, mycotic aneurysm, dislodged plaque Associated with
CAD, stroke, PAD, dehydration, MI, HF
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ACUTE MESENTERIC ISCHEMIA Risks for AMI Age over 50 years old
Atherosclerosis (African Americans as higher risk) AFib
Hypercoaguable states (Critical Care) Epidemiology AMI accounts
for.1% of hospital admissions in US Mortality rate is 71% (AMA
thrombosis is highest mortality rate)
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SIGNS AND SYMPTOMS Abdominal pain out of proportion to
expectation Benign abdominal exams Fear of eating due to
postprandial pain N,V, D GI bleed Bad breath AFib Signs of
sepsis
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SMA BLOCKAGE Ischemia can lead to: Vomiting and diarrhea GI
bleed Necrotic bowel (8-12 hrs) Bacterial overgrowth Perforated
bowel Sepsis HF Multi- organ system failure
http://emedicine.medscape.com/article/191560-overview#showall
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DIAGNOSIS Aortography gold standard Distinguish between SMA
thrombosis and embolism CT scan / ultrasound Not as specific or
sensitive Can see blockage of SMA Can rule out other reasons for
abdominal pain Lab results helpful- not for diagnosis CBC, PPT,
acid base balance, lactate
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TREATMENT Immediate exploratory surgery Remove ischemic/
necrotic bowel Embolectomy In surgery: Peristalsis Coloring Doppler
ultrasonography IV fluorescent under Woodlamp Second look
surgery
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CASE PRESENTATION Presented with abdominal pain out of
proportion Admitting diagnosis: SMA thrombosis PMH: A-Fib, stroke,
CAD, HTN, cardiomyopathy.
CASE PRESENTATION CT scan showed SMA thrombosis Started on TPN
Exploratory laparotomy 30 cm small bowel resected, NGT
decompression Second look surgery GI bleed Pacemaker
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EVIDENCED BASED GUIDELINES Early or late parenteral nutrition:
ASPEN vs. ESPEN Casaer MP, Mesotten D, Hermans G et al Objective:
Comparing the early initiation of PN (European) vs. late initiation
of PN (American and Canadian) Prospective, randomized, controlled,
parallel- group, multicenter trial in Belgium Casaer MP, Mesotten
D, Hermans G, et al. Early versus late parenteral nutrition in
critically ill adults. New England Journal of Medicine. 2011; 365
(6): 506-517. Doi: 10.1056/NEJMoa1102662.
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EVIDENCED BASED GUIDELINES Protocol: 2312 patients receiving PN
in 48 hours 2328 patients receiving PN after seven days Patients
must be at nutritional risk Excluded patients with BMI
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EVIDENCED BASED GUIDELINES PN 48 hours post admission ICU 1 day
shorter LOS in ICU (p